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San Joaquin County PAYM E N T <br /> q ty-Environmental Health Department 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209468-3420 RECEIVED <br /> APPLICATION DEC 31 2025 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP SAN JOAQUIN COUNTY <br /> O <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit'HE ENVIR� �ENT <br /> ❑ Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address "Change of Owner Address <br /> *Additional Employees <br /> State ID#:39-0100-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: CCRC FARMS LLC 39-100 Location: 20750 W MANDEVILLE LEVEE RD STOCKTON <br /> Operator: CCRC FARMS LLC 39-100 Email: <br /> Mailing Address: PO BOX 248,HOLT CA 95234 Facility Phone#: (209)464-2959 <br /> Legal Owner: CCRC FARMS LLC New Owner? ❑ Yes ❑ No <br /> Owner Address: PO BOX 248,HOLT CA 95234 Owner Phone#: (209)164-2959 Email: <br /> Communitv Facilities Provided by Camn• Community Kitchen? ❑ Yes ❑ No <br /> Men: Number ofToilets L Number of Showers �� Number of Lavatories 3 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year. Occupancy Dates: <br /> Buildines Employees <br /> Dormitories / from 0//b/ /2L to /'Z/3// 2(C Crop <br /> SF Dwellings from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year. 5 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> El Inactive Require a PUBLIC WATER SYSTEM Permit <br /> Important: In order to protect your land use status,if camp will not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Fee Schedule <br /> IZ Permanent Camp Annual Permit Fee $54.00+ Number of Employees ✓ , \ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ J,4/ 4j0 <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,C 'ornia Code of Regulations. <br /> 9 <br /> Applicant Name /� L (r�''1C Title � 1 J j/YZL '� ❑Partnership <br /> (Please PRINT or TYPE) <br /> Address Cj/J�C G jf �' C�2�4- Phone(�050 •� �%�n�j <br /> Applicant Signature Date of Application 1 <br /> Amount Paid Date of Payment Payment Type ;�C� Receipt# Received By <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0002992 PR0270100 765 data Salinas <br /> Report#:7067.rpt <br />